Download Elbow pain

DIAGNOSIS AND
MANAGEMENT OF
ELBOW PAIN
ELBOW PAIN
• Lateral elbow pain
• Medial elbow pain
• Posterior elbow pain
Lateral elbow pain - Causes
• Common
– Extensor tendinopathy
– Referred pain (cervical/ upper thoracic/ neural)
• Less common
– Sinovitis of radiohumeral joint
– Posterior interosseous nerve entrapment
• Rare
– Osteocondritis dissecans (capitulum/ radius)
Lateral elbow pain - History
• History of pain
– Onset, duration, character, severity, radiation,
aggravating movements.
– Recent change of activity
– Treatment obtained
– RA , DM
Lateral elbow pain- Examination
1.
2.
3.
4.
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6.
Observation
Active movements
Passive movements
Resisted movements
Palpation
Special tests
Examination of the patient with lateral elbow pain
Active movement
Wrist flexion with forearm fully pronated
Examination of the patient with lateral elbow pain
Resisted muscle testing
Wrist extension
Examination of the patient with lateral elbow
pain
Resisted muscle testing
Extension at third
metacarpophlangeal
joint
Examination of the patient with lateral elbow pain
Restricted muscle testing
Grip strength,
attempt to reproduce
pain
Examination of the patient with lateral elbow pain
Palpation
Lateral epicondyle
Try to locate painful site distal to
the lateral epicondyle
Examination of the patient with lateral elbow pain
Neural tension
test
Upper limb tension test with
forearm pronation to isolate
the radial nerve
Lateral elbow pain - Causes
• Common
– Extensor tendinopathy
– Referred pain (cervical/ upper thoracic/ neural)
• Less common
– Sinovitis of radiohumeral joint
– Posterior interosseous nerve entrapment
• Rare
– Osteocondritis dissecans (capitulum/ radius)
Extensor tendinopathy
• Pathology
– Degeneration of ECRB tendon in proximal 1-2 cm
– Angiofibroblstic hyperplasia which contain large
number of nociceptive nerve endings.
– Microscopic tears in degenerative tissue leading to
scarring
Process leading to development of ERCB tendinoathy
Clinical features
• 40 to 50 years
• Associated with repeated wrist extension activity
• Maximal tendernes is 1 to 2 cm distal to lateral
epicondyle
• Rest of the muscle is tight and hypersensitive
• Tests – Mills’ test , Extension of middle finger
• *perform neural tension tests
• *Examine cervical spine
Treatment
• A combination of different treatments necessary
1. Control of inflammation with
rest, ice, NSAIDS
2.Electrotheraputic modalities
ultrasound, laser, galvanic stimulation
3. Local heat therapy (heat retaining brace)
4. Massage therapy
sustained myofascial tension
transverse friction
digital ischemic pressure
5. Dry needling of trigger points
Treatment cont.
6. Muscle stretching
7. Muscle strengthening
8. Treat other components of pain
9. Correct predisposing factors
10. Corticosteroid injection
11. Surgery
12.Graduated return of activity
Massage techniques
Sustained myofascial tension
Applied to the injured area from proximal to remove fibrous irregularities
Massage techniques
Transverse friction with extensor tissue under tension
(wrist and hand flexion)
Muscle stretching
Stretching of ERCB tendon
Strengthening exercises for elbow
Concentric and eccentric
Treat other components of pain
Cervical mobilization
Correct predisposing factors
Incorrect
Back hand technique
Correct
Steroid Injection
Lateral elbow pain
Posterior interosseous nerve entrapment
Possible entapments @
fibrous bands in front of the
radial head
Recurrent radial vessels
Arcade of Frhose
Tendinous margin of the
ECRB muscle
Posterior interosseous nerve entrapment
Neural stretch
Medial elbow pain
Common
Flexor tendinopathy
medial collateral ligament sprain
acute
chronic
Less common
Ulna nerve compression
avulsion of medial epicondyle
traction apophysitis of medial epicondyle
Referred pain
Medial elbow pain- Flexor tendinopathy
Clinical features
Repeated strain
Localized tenderness just below medial epicondyle
Pain on resisted wrist flexion and pronation
Test – reverse Mills’ test
Treatment – Same liens as lateral tendinopathy
Medial elbow Pain – Flexor tendinopathy
Pain is reproduced with
resisted wrist flexion and
forearm pronation
Stretching exercises for forearm flexors and pronators
Medial elbow pain Medial collateral ligament pain
Acute injury
Chronic injury
Clinical features
localized tenderness
instability in valgus strain
Treatment
activity modification
local electrotheraputic modalities
ulrtasound
muscle strengthening
strapping
Assessment of the integrity of the medial collateral ligament
Medial elbow pain- Ulna nerve compression
Ulna nerve entrapment
Traction injuries
Inflammatory adhesions
Recurrent subluxation of nerve
Irregularities in the bony grove
Clinical features
posteromedial elbow pain
neurological symptoms
tender nerve
TREATMENT
Local massage therapy
Neural streching
Nerve transposition
Nural streching – ulna nerve
The strech can be increased by further shoulder abduction,
Forearm supination and wrist extension
Posterior elbow pain
1. Olecranon bursitis
2. Triceps tendinopathy
3. Posterior impingement
Olecranon bursitis